Nursing Process and Critical Thinking Chapter 4 Nursing Process and Critical Thinking Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 4.1 The Nursing Process and Critical Thinking Theory Explain the use of the nursing process. Identify the components of the nursing process. Compare and contrast the terms critical thinking, clinical reasoning, and clinical judgment. Identify the steps of the problem-solving process. List the steps used in making decisions. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 4.1 The Nursing Process and Critical Thinking Theory Identify ways to improve critical reasoning skills. Apply the critical thinking process to a real-life problem. Discuss the use of critical thinking in nursing. Clinical Practice Apply nursing process to a patient care assignment. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Nursing Process A way of thinking and acting based on the scientific method Used as a tool identify patients’ problems and an organized method to meet patients’ needs It was developed in the 1950s to describe the independent role of the nurse in providing patient care. What are the goals of the nursing process? The goals of this systematic, dynamic process are to explore patients’ health status, identify actual or potential health care problems, determine desired outcomes (results of actions), deliver specific nursing interventions that will solve the problems and promote health, and evaluate caregiving and determine whether outcomes have been achieved. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Nursing Process (cont’d) Components of the nursing process Assessment Nursing diagnosis Planning Implementation Evaluation The construction of a plan of care for the patient is a collaborative process among the nurse, the patient, and other health team members. Patient input during the planning stage results in more success with the plan of care. How is the nursing process similar to other methods used to organize tasks in daily life? The nursing process is similar to other methods used to organize tasks in daily life. In planning a week’s meals at home, the goal is to supply each family member with good nutrition. The assessment, or data collection, phase involves surveying the supplies on hand needed for food preparation. These data are analyzed to determine what must be purchased at the store; to plan specific menus; and to plan for deviation from normal meals, such as school lunches or quick dinners before a child’s basketball game. Implementation includes shopping, preparing and serving the meals, and cleaning up afterward. Evaluation is performed to determine whether the plan was successful: Did the family members eat what was served? Was there too much left over? Was the expected outcome of balanced nutrition for each family member met? If not, should the plan be altered for next week? Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Assessment Collecting, organizing, documenting, and validating a patient’s health data Data are gathered from patient (physical assessment and interview) and family, as well as from the physician and patient’s medical record Data from other health professionals and diagnostic tests included in assessment Using hypothetical examples of patients with prevalent health conditions such as diabetes, congestive heart failure, or from a cancer diagnosis, what are some examples of data that are likely to be gathered from the various sources? This answer will vary. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Nursing Diagnosis Sorting and analyzing the assessment data to identify potential health problems Problems identified during the process are specific nursing diagnoses Nursing diagnoses prioritized and entered into the nursing plan of care Only RNs are to develop a nursing diagnosis. LPN/LVNs use the nursing diagnosis and interventions planned by the RN to provide patient care. It is important to know why the RN develops the nursing diagnosis in order for you to suggest changes based on the patient’s condition. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Planning A series of steps in which the nurse and the patient set priorities and goals to eliminate, diminish, or control identified problems Goals should be stated with specific outcomes Nurse and patient collaborate to choose specific interventions to enable the patient to meet the specific outcomes listed in the plan of care Using your hypothetical patients with prevalent diseases, what are some planning steps likely to be needed? What are the desired outcomes for the diabetic or the CHF patient, for example? The answer will vary. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Implementation Carrying out nursing interventions prioritized during the planning process Some interventions may be delegated or carried out by other members of the health care team Describe the role of documentation in the implementation stage. Appropriate documentation of interventions and patient responses should be documented when they occur. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Evaluation Assessing the patient to evaluate his or her response to the nursing interventions Responses compared with expected outcomes to evaluate whether outcomes have been met Based on results from the evaluation process, the nursing plan of care may need to be changed Again, referring to the hypotheticals, what are some likely outcomes, both healthy and unhealthy? This will vary based on the instructor’s hypotheticals. In the latter cases of poor health outcomes, how might the nursing plan be changed to address these? This will vary based on the instructor’s hypotheticals. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Critical Thinking Required to use the nursing process successfully Means requiring careful judgment Directed, purposeful mental activity by which ideas are evaluated, plans are constructed, and desired outcomes are decided What is clinical reasoning? When we talk about critical thinking inside the clinical setting we call it clinical reasoning. Clinical reasoning is necessary to make reliable observations regarding health status and to draw sound conclusions from the data obtained from the patient and from other sources. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Critical Thinking (cont’d) Problem solving and decision making First define the problem clearly Second, consider all possible alternatives as solutions Third, consider outcomes for each alternative Fourth, predict likelihood of each outcome occurring Finally, choose alternative with best chance of success and fewest undesirable outcomes What is good decision making? Good decision making is choosing the best actions to meet a desired goal and is part of the critical thinking process. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Skills for Critical Thinking Effective reading Effective writing Attentive listening Effective communicating Practicing careful consideration of problems and purposeful thinking, rather than random thinking, will help you develop these skills and attributes. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Critical Thinking in Nursing Requires skills and experience as well as knowledge Influenced by professional standards and codes of ethics The use of facts and details assists in the formation of active resolutions of problems. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Critical Thinking and Nursing (cont’d) Critical thinking and the nursing process Assessment: organized and systematic; includes gathering and recording data Nursing diagnosis requires analysis of data gathered, clustering related information, identifying problem areas, and choosing appropriate nursing diagnoses Planning involves determining specific desired outcomes for each nursing diagnosis During assessment, what specific, detailed data and information will the nurse collect, and from which sources? Collecting, organizing, documenting, and validating data about a patient’s health status. Assessment data are obtained from the patient, the family, the primary care provider, diagnostic tests, and information about the patient from other health professionals. While planning interventions to achieve those outcomes, one considers way to promote optimum wellness and independence. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Critical Thinking and Nursing (cont’d) Critical thinking and the nursing process Implementation involves preparing for and performing the interventions Evaluation involves gathering data to determine if expected outcomes have been achieved During implementation, equipment and supplies are gathered and procedures are thought through before beginning them. Responses to interventions are also assessed. If the expected outcomes are not achieved, the plan of care needs to be reconsidered. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 1 Which of the following is an example of a nurse’s statement that reflects using the scientific method in the nursing process? “I believe that this patient is getting depressed.” “The patient doesn’t look right to me; I think something is wrong.” “The patient’s husband told me that she is feeling very uncomfortable.” “The patient reports more pain than yesterday and her blood pressure is elevated.” Answer: 4 Rationale: “Reporting more pain than yesterday and elevated blood pressure” reflects using the scientific method in the nursing process. The nurse identified a problem of pain, hypothesized that it was greater than the day before, and collected data to evaluate its reality. Believing the patient is depressed or thinking something is wrong reflects intuition. Speaking with the husband reflects information-gathering, which may be used in diagnostic reasoning. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 4.2 Priority Setting Considerations Theory Explain the basic principles of setting priorities for nursing care. List factors to be considered when setting priorities. Clinical Practice Use critical thinking to prioritize care for a patient assignment. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Priority Setting and Work Organization Priority setting (prioritizing): placing nursing diagnoses/interventions in order of importance High priority: life-threatening problems Medium priority: problems that threaten health or coping ability Low priority: problems that do not have a major effect on the person if not attended to that day or week Nurses must be able to prioritize the tasks assigned to them. Prioritizing patient problems is usually based on the adaptation of Maslow’s hierarchy of needs. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Organizing Workload Priorities change as patient conditions change To maintain an organized workload you must: Write out a worksheet; list major tasks to accomplish Be flexible and frequently reorder your tasks Evaluate and reprioritize work plan at least every 2 hours Know when to ask for help and when to delegate a task to others What should a nurse do if he is overwhelmed or does not know how to proceed to address the workload? The nurse must assign some tasks to others and discuss with supervisor. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Application of Problem Solving and Critical Thinking Goal is to avoid having your decision cause injury to anyone With critical thinking skills, you can weigh many factors and skillfully solve problems, making good decisions a majority of the time Operating in critical thinking mode while pursuing nursing studies helps develop clinical judgment needed to practice safe nursing The nursing process is a way of thinking as well as organizing. The nurse is constantly gathering data and evaluating. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Question 2 Which of the following nursing actions is the best example of problem solving? Requesting the IV team to start an antibiotic drip on a patient with a history of being a difficult stick Offering to call the kitchen to provide an alternate breakfast for a patient who does not like cooked cereal Trying several difficult wound dressings to determine which one the patient can apply the most effectively Calling for another pain medication order when the current drug results in the patient experiencing nausea Answer: 3 Rationale: This is an example of the critical thinking strategy of problem solving. The nurse gathers information by using several different products and then uses this information to determine which will work best for the patient. Effective problem solving involves the examination of alternatives. While requesting the IV team solve a problem, there is little critical thinking needed because it would be understood that the IV team would be called under these circumstances. Although calling the kitchen solves a problem, there is little critical thinking needed because it would be understood that the kitchen would be called under these circumstances. Calling for another pain medication order solves a problem, but there is little critical thinking needed because it would be understood that the provider would be called for a new drug order under these circumstances. Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.